Provider Demographics
NPI:1710157078
Name:MELGUIZO-GAVILANES, ISAAC (MD)
Entity Type:Individual
Prefix:DR
First Name:ISAAC
Middle Name:
Last Name:MELGUIZO-GAVILANES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 925
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3689
Mailing Address - Country:US
Mailing Address - Phone:414-384-5111
Mailing Address - Fax:
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 925
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3689
Practice Address - Country:US
Practice Address - Phone:414-384-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102171174400000X
TXP06382084N0400X
WI68347-202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX290780001Medicaid
WI1710157078Medicaid
TX290780001Medicaid